Assessment and Review Form

Email(Required)

Name(Required)

First Last

Date of Assessment(Required)

Choose assessment type(Required)

First time assessment

Scheduled assessment

Choose client

Choose chapter

Choose district (TN)

Tamil Nadu

Select the home (AP)

Andhra Pradesh

Choose the client

Veena, AP

Choose the client

Tabala, AP

Choose the client

Sitara, AP

Select the home (TNCH)

Chengalpattu, Tamil Nadu

Choose the client

Home 1, Chengalpattu, TN

Choose the client

Home 2, Chengalpattu, TN

Choose the client

Home 3, Chengalpattu, TN

First time assessment

Scheduled assessment

Communication Needs

Do you have any specific disabilities which hamper your communication with others?

Yes

No

Choose the disability conditions which hamper your communication

Vision Impairment

Hearing impairment

Speech impairment

Locomotor disability

Other

Add other communication disabilities

Support required for communication

Describe impairement. Mention any kind of assistance, technologies or equipments necessary to support communication

Can you use the following communication equipment well?

Do you prefer to have an Advanced Directive

Yes

No

Add Nominated Representatives

Name

Details

Contact

First time assessment

Scheduled assessment

Placement details

Current placement type

Current Home Again placement category

Current Home Again placement category (other)

Give details here

Name of house currently placed in

Mention house name with district and chapter name

I like my current accomodation

Why you like/don't like your current accommodation?

Current case manager assigned

Scheduled assessment

Support needs and preferences

Client Satisfaction Survey

How satisfied are you with support provided for following domains since last assessment?

	Completely dissatisfied	Mostly dissatisfied	Somewhat dissatisfied	Neither satisfied nor dissatisfied	Somewhat satisfied	Mostly satisfied	Completely satisfied
Health management
Mental Health management
Personal care
Cooking and Eating
Home Management and Shopping
Community and Activities
Social life, skills and relationships
Education
Employment
Financial management
Social entitlements
Safety

First time assessment

Scheduled assessment

Support needs and preferences

Health management (D1)

Health management tasks

- Recognising and communicating when unwell or injured
- Administering basic first aid
- Identifying personal medication
- Taking personal medication as per advice
- Remembering and attending doctors and therapists’ appointments
- Being aware of common, safe, non-prescription over the counter remedies and using appropriately
- Being aware of and able to commit to lifestyle choices related to personal health conditions
- Being aware of stressors and triggers for mental and physical ill health
- Being aware of and applying self-regulation strategies to support physical and mental health

Tell us in detail about how you manage your health

Answer this based on how you manage various tasks under health management.

Have support requirements been identified for Health Management?(Required)

This can include specific tasks, levels of understanding or awareness, safety and risks. If unsure proceed with "yes" to complete this domain.

Yes

No

How would you rate your independence for Health management tasks(Required)

Do you need support with physical tasks, understanding or awareness? This can be based on what the client has described to you and your observations of the client.

	Fully Independent	Independent with a little difficulty	Supervision of 1 carer	Moderate Support of 1 carer	Full support of 1 carer	Support of 2 carers	Unable to manage even with support
Managing overall health
Identifying and taking personal medication as per advice
Recognising and communicating when unwell or injured
Attending health related appointments
Managing basic first aid
Understanding and using non-prescription, over the counter medications and supplements safely

Frequency of support required for Health Management(Required)

	Never/Not Applicable	Occasionally	Once per week	2-6 times per week	Daily	2 times day	3 or more times per day
Managing overall health
Identifying and taking personal medication as per advice
Recognising and communicating when unwell or injured
Attending health related appointments
Managing basic first aid
Understanding and using non-prescription, over the counter medications and supplements safely

What support is required to manage your health?(Required)

Describe both the client's preferences and wishes, as well as your observations of what support they require. Include detailed information about support required its kind, type, timings (day/night, etc.), frequency, number of carers, etc. If no support required, write "None". This directly feeds into the support plan.

Hidden

Based on the Health Management needs, preferences and awareness, are there any safety concerns or risks that need to be identified?

These can be either specific risks or general overall concerns. Are there specific risks or safety hazards that you consider to be significant

Yes

No

List all the safety concerns and risks for Health Management

Score the risk based on above chart. Please describe specific risks or safety hazards that you consider to be significant.

Safety concerns or risk description

Risk Assessment score

Support required to prevent the risk, or to support should the event occur

First time assessment

Scheduled assessment

Mental health (D2)

Mental health management

- Recognising and communicating when mentally not feeling well
- Identifying personal medication
- Taking personal medication as per advice
- Remembering and attending doctors and therapists’ appointments
- Being aware of common, safe, non-prescription over the counter remedies and using appropriately
- Being aware of and able to commit to lifestyle choices related to personal health conditions
- Being aware of stressors and triggers for mental ill health
- Being aware of and applying self-regulation strategies to support mental health

Symptoms of mental health

Memory Problems

Confusion

Concentration problems

Planning problems

Mood problems

Other

Symptoms of mental health (Other)

How do you manage your mental health overall?

Have support requirements been identified for Mental Health Management?

This can include specific tasks, levels of understanding or awareness, safety and risks. If unsure proceed with "yes" to complete this domain.

Yes

No

How would you rate your independence in managing your Mental Health Management

Do you need support with physical tasks, understanding or awareness? This can be based on what the client has described to you and your observations of the client.

	Fully Independent	Independent with a little difficult	Supervision of 1 carer	Moderate Support of 1 carer	Full support of 1 carer	Support of 2 carers	Unable to manage even with support
Overall Mental Health
Memory problems
Confusion
Concentration problems
Planning Problems
Mood

Frequency of Support required for Mental Health Management

What support is required to manage your mental health?

Describe both the client's preferences and wishes, as well as your observations of what support they require. Include detailed information about support required its kind, type, timings (day/night, etc.), frequency, number of carers, etc. If no support required, write "None". This directly feeds into the support plan.

Hidden

Based on the Mental Health Management needs, preferences and awareness, are there any safety concerns or risks that need to be identified?

These can be either specific risks or general overall concerns. Are there specific risks or safety hazards that you consider to be significant

Yes

No

List all the safety concerns and risks for Mental Health Management

Score the risk based on above chart. Please describe specific risks or safety hazards that you consider to be significant.

Safety concerns or risk description

Risk Assessment score

Support required to prevent the risk, or to support should the event occur

Behavioural issues and management

Tell us in detail about concerning behaviours which are currently difficult to monitor, manage, self regulate, etc.

Describe the behaviour, trigger, concerns, or other pertinent issues.

What support is required for behavioural management?

Add detailed information about support required to manage or curb the behaviours at any time. Add if there is need for PRN medication for certain behaviours. If no support required, write "None"

Based on above risk assessment chart: do the following

(1) Name the behaviour, (2) Give the risk score of the behaviour based on the chart and calculation. For level of support identify how many carers should be present, or if other support may be required

Behaviour name and description

Risk score

Support required to prevent the risk, or to support should the event occur

First time assessment

Scheduled assessment

Personal care (D3)

Personal care tasks

- Waking up
- Making bed (folding and laundering bed sheets)
- Caring for teeth and tongue
- Taking a bath
- Managing Menstruation
- Caring for hair
- Caring for skin
- Using toilet
- Choosing preferred clothes
- Wearing clothes
- Changing when clothes get soiled or dirty
- Identifying issues such as missing buttons/wear and tear/inappropriate sizing and repairing or discarding
- Removing facial and body hair -according to personal preferences

Tell us in detail about your personal care management

Answer this based on how you manage various tasks under personal care

Have support requirements been identified for Personal Care?

This can include specific tasks, levels of understanding or awareness, safety and risks. If unsure proceed with "yes" to complete this domain.

Yes

No

How would you rate your independence for personal care tasks

Do you need support with physical tasks, understanding or awareness?

	Fully Independent	Independent with a little difficulty	Supervision of 1 carer	Moderate Support of 1 carer	Full support of 1 carer	Support of 2 carers	Unable to manage even with support
Managing Personal Care
Washing, hair care, brushing teeth, hands and face, changing clothes
Personal hygiene
Toileting
Managing menstruation
Removing facial and body hair - according to personal preferences

Frequency of support required for Personal Care tasks

	Never/not applicable	Occasionally	Once per week	2-6 times per week	Daily	2 times per day	3 or more times per day
Managing Personal Care
Washing, hair care, brushing teeth, hands and face, changing clothes
Personal hygiene
Toileting
Managing menstruation
Removing facial and body hair - according to personal preferences

What support is required to manage your Personal Care?

Describe both the client's preferences and wishes, as well as your observations of what support they require. Include detailed information about support required its kind, type, timings (day/night, etc.), frequency, number of carers, etc. If no support required, write "None". This directly feeds into the support plan.

Hidden

Based on the Personal Care needs, preferences and awareness, are there any safety concerns or risks that need to be identified?

These can be either specific risks or general overall concerns. Are there specific risks or safety hazards that you consider to be significant

Yes

No

List all the safety concerns and risks for Personal Care

Score the risk based on above chart. Please describe specific risks or safety hazards that you consider to be significant.

Safety concerns or risk description

Risk Assessment score

Support required to prevent the risk, or to support should the event occur

First time assessment

Scheduled assessment

Cooking and eating (D4)

Cooking and eating tasks

- Washing hands before and after meals and after using washroom
- Identifying hunger and satiety
- Following regular meal times
- Understanding recipes and ingredients
- Preparing food or drinks
- Serving food or drinks
- Eating food
- Consuming food appropriately at designated place
- Following necessary diet plans

Tell us in detail about how you manage cooking and eating

Answer this based on how you manage various tasks related to cooking and eating

Have any Cooking and Eating support needs been identified?

This can include specific tasks, levels of understanding or awareness, safety and risks. If unsure proceed with "yes" to complete this domain.

Yes

No

How would you rate you independence for Cooking and Eating tasks?

	Fully Independent	Independent with a little difficulty	Supervision of 1 carer	Moderate Support of 1 carer	Full support of 1 carer	Support of 2 carers	Unable to manage even with support
Managing Cooking and Eating Overall
Eating
Drinking
Cooking
Safe use of kitchen tools and home appliances
Understanding nutrition and diet

Frequency of support required for Cooking and Eating

	Never/not applicable	Occasionally	Once per week	2-6 times per week	Daily	2 times per day	3 or more times per day
Managing Cooking and Eating Overall
Eating
Drinking
Cooking
Safe use of kitchen tools and home appliances
Understanding nutrition and diet

What support is required to manage your Cooking and Eating?

Describe both the client's preferences and wishes, as well as your observations of what support they require. Include detailed information about support required its kind, type, timings (day/night, etc.), frequency, number of carers, etc. If no support required, write "None". This directly feeds into the support plan.

Hidden

Based on the Cooking and Eating needs, preferences and awareness, are there any safety concerns or risks that need to be identified?

These can be either specific risks or general overall concerns. Are there specific risks or safety hazards that you consider to be significant

Yes

No

List all the safety concerns and risks for Cooking and Eating

Score the risk based on above chart. Please describe specific risks or safety hazards that you consider to be significant.

Safety concerns or risk description

Risk Assessment score

Support required to prevent the risk, or to support should the event occur

First time assessment

Scheduled assessment

Home management and Shopping (D5)

Home Management and Shopping tasks

- Sweeping and mopping the floor
- Cleaning the washroom
- Recognising repairs and maintenance and calling for appropriate help
- Cleaning kitchen
- Cleaning up after meals
- Washing clothes
- Drying clothes
- Folding and organising clothes
- Laundering the bedding on a regular basis
- Disposing Garbage
- Managing necessary utilities (Switching motor on and off for water, aware of electrical mains to switch off, - organising water during shortage)
- Paying bills
- Taking interest in home decor and aesthetics
- Organising wardrobe and personal assets
- Safe use of kitchen tools and home appliances
- Identifying list of items required for home
- Identifying and assessing personal needs
- Undertaking personal shopping
- Undertaking shopping for home
- Undertaking purchase of groceries and vegetables
- Knowing appropriate shops to purchase different commodities

Tell us in detail about your home management and shopping

Answer this based on how you manage various tasks under this domain

Have support requirements been identified for Home Management?

This can include specific tasks, levels of understanding or awareness, safety and risks. If unsure procede with "yes" to complete this domain.

Yes

No

Have support requirements been identified for Shopping?

This can include specific tasks, levels of understanding or awareness, safety and risks. If unsure procede with "yes" to complete this domain.

Yes

No

How would you rate you independence for Home Management

	Fully Independent	Independent with a little difficulty	Supervision of 1 carer	Moderate Support of 1 carer	Full support of 1 carer	Support of 2 carers	Unable to manage task even with support
Home Management Overall
Cleaning your room
Cleaning Kitchen or Bathroom, taking out garbage
Laundry
Home décor and maintenance needs
Managing home utilities and paying bills

Frequency of support required for Home management tasks

	Never/not applicable	Occasionally	Once per week	2-6 times per week	Daily	2 times per day	3 or more times per day
Home Management Overall
Cleaning your room
Cleaning Kitchen or Bathroom, taking out garbage
Laundry
Home décor and maintenance needs
Managing home utilities and paying bills

How would you rate you independence for Shopping tasks

	Fully Independent	Independent with a little difficulty	Supervision of 1 carer	Moderate support of 1 carer	Full support of 1 carer	Support of 2 carers	Unable to manage even with support
Managing Shopping Overall
Knowing appropriate shops to purchase different commodities and where to find them
Understanding currency for shopping
Shopping for personal items
Shopping for groceries and vegetables
Shopping for home and household items

Frequency of support required for Shopping tasks

	Never/not applicable	Occasionally	Once per week	2-6 times per week	Daily	2 times per day	3 or more times per day
Managing Shopping Overall
Knowing appropriate shops to purchase different commodities and where to find them
Understanding currency for shopping
Shopping for personal items
Shopping for groceries and vegetables
Shopping for home and household items

What support is required for Home Management and Shopping?

Describe both the client's preferences and wishes, as well as your observations of what support they require. Include detailed information about support required its kind, type, timings (day/night, etc.), frequency, number of carers, etc. If no support required, write "None". This directly feeds into the support plan.

Hidden

Based on the Home management and Shopping needs, preferences and awareness, are there any safety concerns or risks that need to be identified?

These can be either specific risks or general overall concerns. Are there specific risks or safety hazards that you consider to be significant

Yes

No

List all the safety concerns and risks for Home management and Shopping

Score the risk based on above chart. Please describe specific risks or safety hazards that you consider to be significant.

Safety concerns or risk description

Risk Assessment score

Support required to prevent the risk, or to support should the event occur

First time assessment

Scheduled assessment

Community and Activities (D6)

Hidden

Provide details of your 1st layer of support which include your friends, family, advocates, other people who know and help you well

Hidden

Please provide details of your 2nd layer of support which include people in community, workplace, volunteering, education, who know and help you

Hidden

Please provide details of your 3rd layer of support which include people in wider community and social groups who know and help you

Mention client relationships. Write the score for Quality and Direction of relationships based on the criteria below:

Quality
Very Positive - 5
Positive - 4
Uncertain - 3
Stressful - 2
Very Stressful - 1

Strength
Very Strong - 5
Strong - 4
Neutral - 3
Weak - 2
Very Weak - 1

Direction
Mutual (Reciprocal) Relationship - 3
One-way Relationship (directed from the client) - 2
One-way Relationship (directed towards the client) - 1

Degree of Proximity

Degree of Proximity in relationship refers to the extent to which the client is near to specific person(s) in terms of distance and time. For example, for client A, the PAs or fellow residents of his/her home, fall under 1st layer of proximity. This is because, they are near to them, come face to face very often, they meet and communicate frequently. But do remember that quality or strength of the relationship need not be positive and strong just because they fall under 1st layer of proximity. For Degree of Proximity in relationship refer to the chart below about different layers.

For Layer 1, mark - 1
For Layer 2, mark - 2
For Layer 3, mark - 3

Client Relationships

Person/Institution name

Relationship Type (Text)

Quality of Relationship (1-5)

Strength of Realtionship (1-5)

Direction of Relationship (1-3)

Degree of Proximity (1-3)

Community engagement tasks

- Planning and undertaking engagements with friends
- Working in team
- Organising an event
- Using public transport and transit
- Participating in leisure activities of choice
- Participating in social activities of the community
- Becoming and being part of various groups or clubs in the community
- Visiting family, friends, relative, other in circle of support
- Hosting and inviting people in support circle, and community to your home
- Celebrating festivals and events of personal significance
- Participating in cultural events of choice such as a temple festival, music concert etc in the local community
- Identifying cultural affiliations and pursuing relevant choices in daily life such as manner of dressing, food and so on
- Identifying spiritual inclinations and pursuing engagement and expression in preferred ways

Tell us in detail about how you manage to engage with the community and involve in various activities

Have any Community Access or Activities support needs been identified?

This can include specific tasks, levels of understanding or awareness, safety and risks. If unsure proceed with "yes" to complete this domain.

Yes

No

Community and activities - Level of independence

Social, leisure or cultural activities

	Fully Independent	Independent with a little difficulty	Supervision of 1 carer	Moderate Support of 1 carer	Support of 1 carer	Support of 2 carers	Unable to manage even with support
Managing community access and activities overall
Accessing the community (physical, use of public transport, road safety)
Participating in events or activities in the community
Managing time and organising activities
Using public transport and transit
Visiting family, friends, relative, other in circle of support

Community and activities - Frequency of support required

	Never/Not applicable	Occasionally	Once per week	2-6 times per week	Daily	2 times per day	3 or more times per day
Managing community access and activities overall
Accessing the community (physical, use of public transport, road safety)
Participating in events or activities in the community
Managing time and organising activities
Using public transport and transit
Visiting family, friends, relative, other in circle of support

What support is required by you for community access and to engage in activities?

Describe both the client's preferences and wishes, as well as your observations of what support they require. Include detailed information about support required its kind, type, timings (day/night, etc.), frequency, number of carers, etc. If no support required, write "None". This directly feeds into the support plan.

Hidden

Based on the Community access and activities needs, preferences and awareness, are there any safety concerns or risks that need to be identified?

These can be either specific risks or general overall concerns. Are there specific risks or safety hazards that you consider to be significant

Yes

No

List all the safety concerns and risks for Community access and activities

Score the risk based on above chart. Please describe specific risks or safety hazards that you consider to be significant.

Safety concerns or risk description

Risk Assessment score

Support required to prevent the risk, or to support should the event occur

First time assessment

Scheduled assessment

Social life, skills and relationships (D7)

Social life, skills and relationships tasks

- Initiating or joining a conversation
- Recognising non-verbal cues
- Speaking coherently
- Welcoming others into a conversation in progress
- Communicating with fellow residents in the home
- Communicating with people outside the home
- Recognising and connecting with personal role in the home
- Understanding various kinds of relationships
- Pursuing friendships, companionships and/or intimate relationships
- Offering help to and receiving help from others
- Recognising others feelings and undertaking appropriate behaviour in social situations
- Recognising one’s own feelings and undertaking appropriate behaviour in social situations
- Being aware of appropriate/inappropriate times and relationships for disclosure of information
- Using modern communication aids
- Recognising and attempting to resolve interpersonal conflicts
- Understanding date and time and using to schedule
- Discussing with and/or seeking help from trusted circle in social networks for difficult personal issues
- Identifying personal emotions and feelings and conveying in a healthy manner
- Identifying and engaging in appropriate means of sexual expression

Tell us in detail about how are you currently handling the the domain of social life, skills, and relationships

Have any Social skills and interpersonal Relationships support needs been identified?

This can include specific tasks, levels of understanding or awareness, safety and risks. If unsure procede with "yes" to complete this domain.

Yes

No

How would you rate your independence for Social skills and interpersonal relationships

	Fully Independent	Independent with a little difficulty	Supervision of 1 carer	Moderate support of 1 carer	Full support of 1 carer	Support of 2 carers	Unable to manage even with support
Managing Social Skills and relationships overall
Communicating with fellow residents in the home
Communicating with people outside the home
Understanding and/or pursuing friendships, companionships and/or intimate relationships
Recognising own and others feelings and undertaking appropriate behaviour in social situations
Identifying and engaging in appropriate means of sexual expression

Frequency of support for Social skills and Interpersonal relationships

	Never/not applicable	Occasionally	Once per week	2-6 times per week	Daily	2 times per day	3 or more times per day
Managing Social Skills and relationships overall
Communicating with fellow residents in the home
Communicating with people outside the home
Understanding and/or pursuing friendships, companionships and/or intimate relationships
Recognising own and others feelings and undertaking appropriate behaviour in social situations
Identifying and engaging in appropriate means of sexual expression

What support is required to manage your Social life, Skills, and Relationships?

Describe both the client's preferences and wishes, as well as your observations of what support they require. Include detailed information about support required its kind, type, timings (day/night, etc.), frequency, number of carers, etc. If no support required, write "None". This directly feeds into the support plan.

Hidden

Based on the Social Skills and interpersonal relationships needs, preferences and awareness, are there any safety concerns or risks that need to be identified?

These can be either specific risks or general overall concerns. Are there specific risks or safety hazards that you consider to be significant

Yes

No

List all the safety concerns and risks for Social Skills and Interpersonal Relationships

Score the risk based on above chart. Please describe specific risks or safety hazards that you consider to be significant.

Safety concerns or risk description

Risk Assessment score

Support required to prevent the risk, or to support should the event occur

First time assessment

Scheduled assessment

Education (D8)

Total number of years education

Please enter a number from 1 to 20.

Current education status

Attending course

Skill/vocational training

Both of the above

Not pursuing anything at the moment

Other

Other education status

Tell us in detail about your past and present education, any skill/vocational training or other courses

If there is no present or past details to share, write "None"

Have any Education support needs been identified?

This can include specific tasks, levels of understanding or awareness, safety and risks. If unsure procede with "yes" to complete this domain.

Yes

No

How would you rate your independence in education/training?

What is the frequency of support required to help you with your education/training?

Tell us if you have any specific interest in education or skill development. Also explain what support is required for pursuing your present or future education dreams, courses or skill training?

Describe both the client's preferences and wishes, as well as your observations of what support they require. Include detailed information about support required its kind, type, timings (day/night, etc.), frequency, number of carers, etc. If no support required, write "None". This directly feeds into the support plan.

Hidden

Based on the Education needs, preferences and awareness, are there any safety concerns or risks that need to be identified?

These can be either specific risks or general overall concerns. Are there specific risks or safety hazards that you consider to be significant

Yes

No

List all the safety concerns and risks for Education

Score the risk based on above chart. Please describe specific risks or safety hazards that you consider to be significant.

Safety concerns or risk description

Risk Assessment score

Support required to prevent the risk, or to support should the event occur

First time assessment

Scheduled assessment

Employment (D9)

Current work status

Mark as "Employed", if the client is in paid position that is remunerated at par with market wages for not less than 20 hrs per week, either within the Banyan facility or outside)

Employed

Engaged in work

Not engaged in work

Other

What type of employment?

Internal employment with the Banyan

External employment

Other

Other work status

Other type of employment

Describe about your employment or any work engagement (present and past)

If no previous or present employment or work engagement, write "None"

Have any Employment support needs been identified?

This can include specific tasks, levels of understanding or awareness, safety and risks. If unsure procede with "yes" to complete this domain.

Yes

No

How would you rate your independence for following tasks under Employment domain?

	Fully Independent	Independent with a little difficulty	Supervision of 1 carer	Support of 1 carer	Support of 2 carers	Unable to manage even with support
Managing work overall
Traveling to place of employment
Reporting for or engaging in work consistently
Managing work relationships and Understanding role at work
Using adaptive coping mechanisms to deal with work related stress
Managing demands of both employment and caring for self and home

What is the frequency of support required to help you for following tasks under Employment domain?

	Never	Occasionally	Once per week	2-6 times per week	Daily	2 times day	3 or more times per day
Managing work Overall
Traveling to place of employment
Reporting for or engaging in work consistently
Managing work relationships and Understanding role at work
Using adaptive coping mechanisms to deal with work related stress
Managing demands of both employment and caring for self and home

What support is required for your employment, work engagement, managing your work, future career?

Describe both the client's preferences and wishes, as well as your observations of what support they require. Include detailed information about support required its kind, type, timings (day/night, etc.), frequency, number of carers, etc. If no support required, write "None". This directly feeds into the support plan.

Hidden

Based on the Employment needs, preferences and awareness, are there any safety concerns or risks that need to be identified?

These can be either specific risks or general overall concerns. Are there specific risks or safety hazards that you consider to be significant

Yes

No

List all the safety concerns and risks for Employment

Score the risk based on above chart. Please describe specific risks or safety hazards that you consider to be significant.

Safety concerns or risk description

Risk Assessment score

Support required to prevent the risk, or to support should the event occur

First time assessment

Scheduled assessment

Financial management (D10)

How much is your salary?

INR per month

Please enter a number from 0 to 100000.

Incentives received for work

(approx)

Please enter a number from 0 to 100000.

Other sources of Income

(Apart from salary and incentives)

None

Family

Friends

Government Allowances

Other

Do you have other sources of income (Other)

If Government allowances or Other, please describe here

Detail list of income earned from other sources

Income source

Income amount (INR per month)

Total current income per month

include incentives, salary and other sources

Please enter a number greater than or equal to 0.

Finance management

- Understanding currency and recognising denominations
- Understanding and performing simple calculations
- Understanding concept of trade
- Being aware of personal income
- Saving money
- Being aware of money on hand
- Paying maintenance bills
- Planning and budgeting for expenses
- Understanding loans, repayments and dues
- Operating a bank account

Tell us in detail how are you currently managing your finances

Have any Financial Management support needs been identified?

This can include specific tasks, levels of understanding or awareness, safety and risks. If unsure procede with "yes" to complete this domain.

Yes

No

How would you rate your independence for Financial Management tasks

	Fully Independent	Independent with a little difficulty	Supervision of 1 carer	Moderate Support of 1 carer	Full support of 1 carer	Support of 2 carers	Unable to manage even with support
Managing Finances overall (understanding of trade)
Understanding and performing simple calculations
Being aware of personal income and money on hand
Planning, budgeting and saving money
Operating a bank account
Understanding loans, repayments and dues

Frequency of support for Financial Management

	Never/not applicable	Occasionally	Once per week	2-6 times per week	Daily	2 times day	3 or more times per day
Managing Finances overall (understanding of trade)
Understanding and performing simple calculations
Being aware of personal income and money on hand
Planning, budgeting and saving money
Operating a bank account
Understanding loans, repayments and dues

What support is required to manage your finances?

Describe both the client's preferences and wishes, as well as your observations of what support they require. Include detailed information about support required its kind, type, timings (day/night, etc.), frequency, number of carers, etc. If no support required, write "None". This directly feeds into the support plan.

Hidden

Based on the Financial Management needs, preferences and awareness, are there any safety concerns or risks that need to be identified?

These can be either specific risks or general overall concerns. Are there specific risks or safety hazards that you consider to be significant

Yes

No

List all the safety concerns and risks for Financial Management

Score the risk based on above chart. Please describe specific risks or safety hazards that you consider to be significant.

Safety concerns or risk description

Risk Assessment score

Support required to prevent the risk, or to support should the event occur

First time assessment

Scheduled assessment

Social entitlements (D11)

Hidden

Select the social entitlements which the client does not have access to:

Hidden

Select the social entitlements for which application has been made, but waiting for approval and receiving the document:

Do you have and how useful are the following social entitlements

	I don't have this	Applied & Waiting	Not used till now	Not at all useful	Slightly useful	Moderately useful	Very useful	Extremely useful
Aadhar card
Voter ID
Disability card
Disability allowance
Medical insurance
Pan card
MNREGA card
Bank account
Jan dhan account
Ration card
Gas connection
Post office savings account
Pension

Have you applied or possess other social entitlements that is not mentioned above

Possess

Applied for

Other social entitlements which I possess

List those not mentioned above

Other social entitlements for which application has been made

List those not mentioned above

Describe the difficulties faced to procure or process particular social entitlement for the client

Tell us in detail how are the social entitlements benefitting you in your day-to-day life. Are there any support required to know more about specific documents and increase their personal utility?

Social entitlements have strengthened my citizenship rights and increased my civic participation

First time assessment

Scheduled assessment

General safety (D12)

Safety

- Being aware of personal address, emergency telephone numbers and safe spaces
- Being aware of safety processes in case of emergencies
- Identifying appropriate touch based on relationship and escalating for help
- Identifying abusive and exploitative situations or relationships and escalating for help
- Being aware of potential risks in daily life situations
- Being able to navigate roads and community spaces safely
- Being able to assert personal boundaries and space
- Understanding and following safety precautions for home
- Using appropriate facilities to secure safety of precious personal belongings

Tell us in detail about how you manage your General safety involving tasks like those mentioned above

Have any needs been identified with regard to General Safety involving above tasks?

Yes

No

How would you rate your independence with general safety

	Fully Independent	Independent with a little difficulty	Supervision of 1 carer	Moderate support of 1 carer	Full support of 1 carer	support of 2 carers	Unable to manage even with support
Managing overall General Safety
Being aware of personal address, emergency telephone numbers and safe spaces
Being aware of safety processes in case of emergencies
Identifying appropriate touch based on relationship and escalating for help
Identifying abusive and exploitative situations or relationships and escalating for help
Being aware of potential risks in daily life situations

Do you require support for any of these aspects of safety and how often

	Never/Not Applicable	Occasionally	once a week	2-6 times per week	Daily	2 times per day	3 or more times per day
Managing overall General Safety
Being aware of personal address, emergency telephone numbers and safe spaces
Being aware of safety processes in case of emergencies
Identifying appropriate touch based on relationship and escalating for help
Identifying abusive and exploitative situations or relationships and escalating for help
Being aware of potential risks in daily life situations

What support is required for General Safety?

Describe both the client's preferences and wishes, as well as your observations of what support they require. Include detailed information about support required its kind, type, timings (day/night, etc.), frequency, number of carers, etc. If no support required, write "None". This directly feeds into the support plan.

Are any safety concerns or risks that have been identified across domains of daily living?

These can be either specific risks or general overall concerns. Are there specific risks or safety hazards that you consider to be significant?

Yes

No

List all the safety concerns and risks for all domains

This is a risk assessment, for all significant concerns, such as self-harm, road safety behaviour etc. Score the risk based on above chart. Please describe specific risks or safety hazards that you consider to be significant.

Domain name

Safety concerns or risk description

Risk Assessment score

Support required to prevent or reduce the risk, or to support should the event occur

First time assessment

Scheduled assessment

Decision making (D13)

Decision making is about a client’s ability to make specific decisions regarding their day to day lives, and what level of capacity they have to make these decisions. This is to raise concerns regarding a person’s mental capacity to make certain decisions, and whether a mental capacity assessment should be sought.
A person can have different levels of capacity for different decisions, and we need to take into account their understanding, whether they need support and how they can be supported to make an informed choice. What is the cause of the difficulty in making a decision? Is it due to memory, confusion, lack of awareness, something that is a trigger? Highlighting reasons will help understand if there is a need for a mental capacity assessment
If a person is making a decision that you do not agree with, this does not mean they do not have capacity to make that choice. We should be supporting informed decision making supporting their independence.

Tell us in detail about how you make decisions in your life

Consider various daily situations part of above domains. Is the client able to make decisions with support?

Have you identified any concerns around the client's mental capacity in any of the domains?

Yes

No

What domains have raised concerns in terms of decision making and the client's mental capacity, and what level of priority applies?

	No concerns	Low concern	Moderate concern	High concern	Extreme concern	Not applicable	Unknown
Health Management
Mental Health Management
Behaviour Management
Personal Care
Cooking and Eating
Home Management and Shopping
Community access and activities
Social life and personal relationships
Education
Employment
Financial Management
General Safety

Frequency of support required for Decision Making if of moderate or higher concern

	Never/not applicable	Occasionally	Once per week	2-6 times per week	Daily	2 times day	3 or more times per day
Health Management
Mental Health Management
Behaviour Management
Personal Care
Cooking and Eating
Home Management and Shopping
Community access and activities
Social life and personal relationships
Education
Employment
Financial Management
General Safety

Tell us in detail about support required for decision making

Describe both the client's preferences and wishes, as well as your observations of what support they require. Include detailed information about support required its kind, type, timings (day/night, etc.), frequency, number of carers, etc. If no support required, write "None". This directly feeds into the support plan.

Based on the Decision making for each domain which domains may require a mental capacity assessment?

Any decision that is of "Moderate" and above, please tick domains where you feel a mental capacity assessment is required.

First time assessment

Scheduled assessment

Support Planning

Write in detail the assessment conclusion

How well does the client manage? What are their key areas that they want support in?

Write in detail what needs to be put in place to meet their needs

Which domains does the client require support? How will their needs be met?

Date when Scheduled Review should next be completed

	Never used it	Strongly disagree	Disagree	Neutral	Agree	Strongly Agree
Landline
Mobile Phone (not smart)
Smart phone
Tablet
Computer

Client Assessment Form

Scheduled assessment

Choose client

First time assessment

Scheduled assessment

Demographic details

First time assessment

Scheduled assessment

Communication Needs

First time assessment

Scheduled assessment

Placement details

Health conditions and medication

First time assessment

Scheduled assessment

Scheduled assessment

Support needs and preferences

Client Satisfaction Survey

First time assessment

Scheduled assessment

Support needs and preferences

Health management (D1)

First time assessment

Scheduled assessment

Mental health (D2)

Mental health management

Behavioural issues and management

First time assessment

Scheduled assessment

Personal care (D3)

First time assessment

Scheduled assessment

Cooking and eating (D4)

First time assessment

Scheduled assessment

Home management and Shopping (D5)

First time assessment

Scheduled assessment

Community and Activities (D6)

First time assessment

Scheduled assessment

Social life, skills and relationships (D7)

First time assessment

Scheduled assessment

Education (D8)

First time assessment

Scheduled assessment

Employment (D9)

First time assessment

Scheduled assessment

Financial management (D10)

First time assessment

Scheduled assessment

Social entitlements (D11)

First time assessment

Scheduled assessment

General safety (D12)

First time assessment

Scheduled assessment

Decision making (D13)

First time assessment

Scheduled assessment

Support Planning